Background: Many patients treated for major
depression require more than one antidepressant trial to achieve
or sustain response. However, the literature provides few
treatment algorithms or effectiveness studies that empirically
support "next-step" options available to clinicians. We
conducted a survey of psychiatrists and other medical specialists
who treat depression to ascertain what clinicians actually do
when faced with patients who suboptimally respond to an adequate
course of selective serotonin reuptake inhibitor (SSRI) therapy.

Method: Attendees at a psychopharmacology course
(N = 801) were queried about their top choices for
antidepressant-treatment nonresponders: a minimal responder after
4 weeks of adequate SSRI treatment, a partial responder after 8
weeks of adequate SSRI therapy, a nonresponder after 8 weeks of
adequate SSRI therapy, and a relapser on long-term SSRI
maintenance therapy. Choices included raising the dose,
augmenting or combining with another agent, switching to a second
SSRI, or switching to a non-SSRI agent.

Results: 432 (54%) of the surveys were returned.
Raising the dose was the most frequently reported next-step
strategy for a patient with minimal response after 4 weeks of
adequate SSRI therapy, partial response after 8 weeks of adequate
SSRI therapy, and relapse on long-term SSRI therapy. Switching to
a non-SSRI agent was the most frequently chosen option for
nonresponders to an adequate trial of SSRI therapy.

Conclusion: Our findings suggest that clinicians
select different next-step strategies when patients are
nonresponders versus when patients are partial responders or
relapsers.